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Research Interests:
Research Interests:
The need for health care reform in South Africa is acknowledged by the government as well as by the non-governmental health sector. There is, however, no unanimity regarding the nature of the envisaged reform. A country-wide postal survey... more
The need for health care reform in South Africa is acknowledged by the government as well as by the non-governmental health sector. There is, however, no unanimity regarding the nature of the envisaged reform. A country-wide postal survey of 700 private sector general practitioners (GPs) from a commercial database of 5,000 was conducted to explore attitudes towards health care. A response rate of 67.4% was obtained. Respondents were mostly male (92%) and urban-based (64%). The median age was 42 years. Most respondents: (i) believed health care to be a right for all citizens; (ii) favoured private or a combination of private and public funding mechanisms with fee-for-service arrangements; (iii) opposed cost-containment measures imposed by funders, e.g. medical aids; and (iv) believed doctors should be responsible for primary care in under-served areas. After sex, age, location (urban versus rural) and GP postgraduate qualification had been controlled for by means of logistic regressi...
Research Interests: South Africa, Humans, Female, Male, Aged, and 4 moreMiddle Aged, Questionnaires, Adult, and Professional Competence
In the year ending 30 June 1989, 26.8% of 5,345 deaths in the Port Elizabeth area were classified as ill-defined. A study was undertaken in an attempt to identify the reasons for the high proportion of such deaths. Copies of all death... more
In the year ending 30 June 1989, 26.8% of 5,345 deaths in the Port Elizabeth area were classified as ill-defined. A study was undertaken in an attempt to identify the reasons for the high proportion of such deaths. Copies of all death notifications and death register forms of black people in the area served by the Port Elizabeth City Health Department were collected for a 6-week period. Of the 316 deaths, 154 (48.7%) were certified by medical practitioners at a hospital, 158 (50%) by the police and 4 (1.3%) by private medical practitioners. Of the police-certified deaths 116 (73.4%) were recorded as due to 'natural causes', with the remainder being submitted to autopsy. Of the hospital deaths, 26% were not adequately described in the section for the cause of death on the death certificate. Review of national mortality data for 1985 showed that only 29.9% of ill-defined deaths (in all population groups) were certified by a medical practitioner. The prime source of deaths clas...
A postal survey of workplace smoking restrictions among the member organisations of the Cape Chamber of Industries was carried out in 1989. The response rate was 57.1%. Of the 572 respondent organisations, 66.1% had some smoking... more
A postal survey of workplace smoking restrictions among the member organisations of the Cape Chamber of Industries was carried out in 1989. The response rate was 57.1%. Of the 572 respondent organisations, 66.1% had some smoking restrictions. Large workplaces were more likely to restrict smoking than small workplaces: 42.0% of those with fewer than 10 employees had restrictions, increasing to 90.9% of those with more than 500 employees. Organisations producing manufactured goods (other than engineering) were more likely to have restrictions than non-manufacturing concerns. Smoking was commonly restricted on the factory floor (61.3%) and in warehouses (55.8%), but only 7.4% prohibited smoking in shared offices. The reasons for smoking restrictions stated most frequently were the fire hazard (85.3%) and legislation (66.0%). Only 29.1% stated that health care concerns were an important reason for restrictions, while a further 16.3% stated that health was a minor reason for restrictions...
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Background: In resource-limited countries, the use of DBS as an alternative to plasma for the determination of HIV-1 viral load is an important intervention for ART programmes intending to scale up access to viral load monitoring at... more
Background: In resource-limited countries, the use of DBS as an alternative to plasma for the determination of HIV-1 viral load is an important intervention for ART programmes intending to scale up access to viral load monitoring at national level. DBS have been shown to correlate well with plasma using RNA-specific viral load assays; however, higher viral load results have been previously reported when using non RNA-specific viral load methods such as the Roche Amplicor assay. We conducted a study to assess the diagnostic accuracy of DBS using the COBAS Ampliprep/COBAS TaqMan (CAP/CTM). Methods: 118 finger prick DBS, venous blood DBS and plasma specimens were analyzed in the National Microbiology Reference Laboratory in Harare, Zimbabwe. Specimens were collected from ART patients attending two rural OI clinics in Buhera and Tsholotsho districts and one urban OI clinic in Harare. Sensitivity, specificity, correlation and agreement analysis were used to assess diagnostic performance ...
Cholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around... more
Cholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around Lake Chilwa. This paper describes the outbreak response and lessons learned for prevention and management of future outbreaks. Starting in January 2010, Médecins Sans Frontières (MSF) helped District Health Management Teams (DHMTs) to distribute educational materials, water disinfectant and hygiene supplies, and oral rehydration solution (ORS) in fishing communities. MSF also supported case management by mentoring health workers and providing equipment and supplies. A total of 1,171 cholera cases and 21 deaths were reported in the districts around the lake, with cases also being reported on the Mozambican side of the lake. The attack rate was highest among people living on or around the lake, particularly among fishermen. Samples of lake water had high...
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In 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from <250 cells/µl and <350 cells/µl, but at the same time only 8.8% of facilities in Malawi with HIV services provided CD4... more
In 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from <250 cells/µl and <350 cells/µl, but at the same time only 8.8% of facilities in Malawi with HIV services provided CD4 testing. We conducted a record review at 10 rural clinics in Thyolo District to assess the impact of introducing CD4 testing on identifying patients eligible for ART. We abstracted CD4 counts of all ART-naïve, HIV-infected patients with WHO clinical stages 1 and 2 and an initial CD4 test between May 2008 and June 2009. At four clinics, we also abstracted CD4 counts of patients not initially eligible for ART who were retested before April 2010. Of 1,113 patients tested, the initial CD4 was "≤250 cells/µl" and "≤350 cells/µl" in 534 (48.0%). Of 203 patients with follow-up results, the most recent CD4 was ≤250 cells/µl in 34 (24.5%), and ≤350 cells/µl in 64 (46.0%). CD4 testing in rural clinics is feasible and identifies many patients eli...
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Research Interests:
Prevention of new HIV infections is a critical imperative for South Africa; the prevention of mother-to-child transmission (PMTCT) is one of the most efficacious HIV prevention interventions. Assessment of a PMTCT programme to determine... more
Prevention of new HIV infections is a critical imperative for South Africa; the prevention of mother-to-child transmission (PMTCT) is one of the most efficacious HIV prevention interventions. Assessment of a PMTCT programme to determine missed opportunities. The Kouga local service area (LSA), bordering Nelson Mandela Bay Municipality (Port Elizabeth) in the Eastern Cape. An assessment was conducted in 2007 before implementing technical support for strengthening the PMTCT programme, including: interviews with 20 PMTCT managers, 4 maternity staff and 27 other health workers on service provision, management, infrastructure, human resources and the health information system; 296 antenatal clinic users on their service perceptions; 70 HIV-positive women on HIV knowledge, infant feeding, coping, support and service perceptions; 8 representatives from community organisations and 101 traditional health practitioners (THPs). Observations were conducted during site visits to health facilitie...
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Background / Purpose: The World Health Organization (WHO) recommends that patients taking antiretroviral therapy (ART) for HIV have routine viral load (VL) monitoring to identify patients with poor adherence or viral resistance. The... more
Background / Purpose: The World Health Organization (WHO) recommends that patients taking antiretroviral therapy (ART) for HIV have routine viral load (VL) monitoring to identify patients with poor adherence or viral resistance. The purpose of this analysis was to identify factors associated with a high VL, in order to identify groups that should be prioritised for VL testing. Main conclusion: A substantial proportion of patients without suspected treatment failure had a high VL, demonstrating the importance of routine VL monitoring. However, programs phasing-in routine VL monitoring should prioritise testing of those with suspected treatment failure or aged <25 years, and should also provide interventions to improve ART adherence among patients with a high VL in order to avert treatment failure.
Background / Purpose: Among HIV patients on antiretroviral therapy (ART), a high viral load (VL) may indicate non-adherence or viral resistance. Among poorly-adherent patients, enhanced adherence counselling (EAC) may lead to viral... more
Background / Purpose: Among HIV patients on antiretroviral therapy (ART), a high viral load (VL) may indicate non-adherence or viral resistance. Among poorly-adherent patients, enhanced adherence counselling (EAC) may lead to viral resuppression and prevent development of viral resistance. Main conclusion: While many patients had viral resuppression after EAC, the majority had a persistently elevated VL. These findings confirm the importance of routine VL testing within the first year of starting ART, and repeat VL testing before deciding to switch to second-line ART. Further study is essential to identify appropriate algorithms and interventions to target adherence support effectively and to avert treatment failure.
Background: CD4 testing is required to identify people eligible for antiretroviral therapy. Point-of-care (POC) CD4 testing enables persons who test HIV-positive to be assessed for antiretroviral therapy (ART) eligibility the same day,... more
Background: CD4 testing is required to identify people eligible for antiretroviral therapy. Point-of-care (POC) CD4 testing enables persons who test HIV-positive to be assessed for antiretroviral therapy (ART) eligibility the same day, thus minimizing pre-ART loss to follow-up. Médecins Sans Frontières (MSF) has introduced POC CD4 testing using Pima CD4 analyzers (Alere) in MSF-supported HIV projects in 9 countries. Several projects reported a high frequency of invalid results using Pima CD4 analyzers prompting us to assess the extent of the problem and to try to identify causes of invalid results. Description: MSF projects using Pima CD4 devices were contacted and asked to submit Pima CD4 testing records, and to complete a questionnaire on the use of Pima CD4 analyzers in the project. Adjusted risk ratios (aRR) were calculated using binary regression analyses to identify factors associated with errors. Pima analyzers that had been used to perform < 100 tests, tests performed by ...
Background / Purpose: High cost is one of the obstacles hampering the roll out of HIV-1 viral load testing. Logistic difficulties associated with plasma is another obstacle. The combination of pooled testing algorithms and the use of... more
Background / Purpose: High cost is one of the obstacles hampering the roll out of HIV-1 viral load testing. Logistic difficulties associated with plasma is another obstacle. The combination of pooled testing algorithms and the use of dried blood spots as a sample type might prove to be a good combination to help overcome these challenges. Main conclusion: Pooled viral load testing of dried blood spot samples was shown to be efficient in saving reagent costs up to 50%. In addition, precision of the test was maintained with negative predictive values, to predict virological treatment failure, exceeding 97%.
OBJECTIVES: Examine how characteristics of heterosexual main sexual partnerships affect the odds of experiencing condom breakage/slippage or partial use (applying late/removing early) during vaginal sex. METHODS: Secondary analysis of... more
OBJECTIVES: Examine how characteristics of heterosexual main sexual partnerships affect the odds of experiencing condom breakage/slippage or partial use (applying late/removing early) during vaginal sex. METHODS: Secondary analysis of data from an STI prevention trial (RESPECT-2) conducted in 3 public STD clinics. Participants described sexual behaviors, personal and partner characteristics for up to three partners on computer-assisted interviews every 3 months for a year. We analyzed rates of condom breakage/slippage and partial use. Logistic GEE models were used to account for within-participant correlation of repeated measures. RESULTS: 2758 participants reported vaginal sex in the prior 3 months in at least one interview (8807 partnerships). Condoms were used in 4557 partnerships; 22% reported breakage/slippage and 26% reported partial use. The odds for both condom problems increased by 1% with each use (p<.05). Breakage/slippage was more likely in partnerships when the respo...
In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the... more
In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, ...
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CD4+ T-cell testing of blood specimens collected in standard EDTA Vacutainer tubes and transported at ambient temperature, must be completed within 48 hours with the BD FACSCount™ flow cytometer, restricting specimen collection in remote... more
CD4+ T-cell testing of blood specimens collected in standard EDTA Vacutainer tubes and transported at ambient temperature, must be completed within 48 hours with the BD FACSCount™ flow cytometer, restricting specimen collection in remote clinics with no on-site testing and limited specimen transport services. We conducted a study in Buhera District, Zimbabwe, to assess the stability and accuracy of CD4+ T-cell results of samples collected in Stabilization Tubes (ST) and stored at ambient temperature for varying time periods. Paired EDTA and ST samples were collected from 51 HIV-positive patients aged 18 years and older. CD4+ T-cell testing was done on arrival in the laboratory (Day 0). ST samples were retested on Days 3, 5, and 7. Nineteen ST samples were stored for an additional week and retested on Day 14. There was a strong correlation between absolute CD4+ T-cell counts measured in the EDTA Day 0 reference sample and Day 7 ST sample (Spearman's rho: 0.9778; mean difference: ...
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Research Interests: Adolescent, Biological Sciences, Humans, United States, Female, and 13 moreAnimals, Sexually transmitted infections, Trichomonas vaginalis, Incidence, Risk factors, Prevalence, Risk Factor, Human immunodeficiency virus, Adult, Risk Factors, Cross Sectional Studies, Sexually Transmitted Diseases, and Sexually Transmitted Disease
Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low. A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV... more
Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low. A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months. Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups. Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.
Research Interests: Treatment Outcome, Adolescent, Counseling, Biological Sciences, California, and 17 moreHumans, United States, Female, Sexually transmitted infections, Male, New Jersey, Randomised Controlled Trial, Colorado, HIV testing, Questionnaires, Adult, Risk Reduction, Randomized Controlled Trial, Sexually Transmitted Diseases, Sexually Transmitted Disease, Confidence Interval, and Relative Risk
Research Interests:
Research Interests: Heterosexuality, Risk Taking, Adolescent, Biological Sciences, Humans, and 20 moreUnited States, Female, Sexually transmitted infections, Male, Sexual Behavior, Behavior change, Condom use, Prevalence, HIV testing, Adult, Cross Section, Randomized Controlled Trial, Highly Active Antiretroviral Therapy, Study design, Risk Behavior, Condoms, Sexual Partners, Cross Sectional Studies, Sexual Risk Behavior, and Sexually Transmitted Diseases
HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months. The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling... more
HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months. The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78-1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group. Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.